RÉSUMÉ
BACKGROUND: Recent clinical trials established the benefit of dual antiplatelet therapy with aspirin and clopidogrel (DAPT-AC) in early-presenting patients with minor ischemic stroke. However, the impact of these trials over time on the use and outcomes of DAPT-AC among the patients with nonminor or late-presenting stroke who do not meet the eligibility criteria of these trials has not been delineated. METHODS AND RESULTS: In a multicenter stroke registry, this study examined yearly changes from April 2008 to August 2022 in DAPT-AC use for stroke patients ineligible for CHANCE/POINT (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events/Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke) clinical trials due to National Institutes of Health Stroke Scale >4 or late arrival beyond 24 hours of onset. A total of 32 118 patients (age, 68.1±13.1 years; male, 58.5%) with National Institutes of Health Stroke Scale of 4 (interquartile range, 1-7) were analyzed. In 2008, DAPT-AC was used in 33.0%, other antiplatelets in 62.7%, and no antiplatelet in 4.3%. The frequency of DAPT-AC was relatively unchanged through 2013, when the CHANCE trial was published, and then increased steadily, reaching 78% in 2022, while other antiplatelets decreased to 17.8% in 2022 (Ptrend<0.001). From 2011 to 2022, clinical outcomes nonsignificantly improved, with an average relative risk reduction of 2%/y for the composite of stroke, myocardial infarction, and all-cause mortality, both among patients treated with DAPT-AC and patients treated with other antiplatelets. CONCLUSIONS: Use of DAPT-AC in stroke patients with stroke ineligible for recent DAPT clinical trials increased markedly and steadily after CHANCE publication in 2013, reaching deployment in nearly 4 of every 5 patients by 2022. The secondary prevention in patients with ischemic stroke seems to be gradually improving, possibly due to the enhancement of risk factor control.
Sujet(s)
Acide acétylsalicylique , Clopidogrel , Bithérapie antiplaquettaire , Accident vasculaire cérébral ischémique , Antiagrégants plaquettaires , Enregistrements , Humains , Clopidogrel/usage thérapeutique , Acide acétylsalicylique/usage thérapeutique , Mâle , Sujet âgé , Femelle , Accident vasculaire cérébral ischémique/traitement médicamenteux , Accident vasculaire cérébral ischémique/mortalité , Accident vasculaire cérébral ischémique/diagnostic , Accident vasculaire cérébral ischémique/prévention et contrôle , Bithérapie antiplaquettaire/effets indésirables , Antiagrégants plaquettaires/usage thérapeutique , Antiagrégants plaquettaires/effets indésirables , Adulte d'âge moyen , Résultat thérapeutique , Sujet âgé de 80 ans ou plus , Facteurs temps , Japon/épidémiologie , Prévention secondaire/méthodes , Prévention secondaire/tendances , Association de médicaments , Facteurs de risqueRÉSUMÉ
BACKGROUND AND OBJECTIVES: Understanding trends in the use of medications for secondary stroke prevention is crucial for identifying areas for improvement in stroke care. We examined the use of lipid-lowering, antihypertensive, glucose-lowering, oral anticoagulant, and antiplatelet medications after ischemic stroke hospitalization, from 2005 to 2021. METHODS: Using nationwide registries in Denmark, we identified a cohort of patients discharged from hospital with a first-time or recurrent ischemic stroke (N = 150,744). Stratified by calendar year, we ascertained the 180-day probability of filling a prescription for the abovementioned medications after discharge. We further assessed factors associated with medication use. RESULTS: From 2005 to 2021, lipid-lowering medication use increased from 58.3% to 82.0%; atorvastatin use rose from 2.1% to 64.8% and simvastatin use decreased from 55.7% to 8.6%. Antihypertensive medication use remained stable, at approximately 89%, and various antihypertensive classes were used comparably. Glucose-lowering medication use increased from 71.5% in 2005 to 84.1% in 2021, driven primarily by an increase in metformin use (from 28.0% to 59.5%). Use of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors continually increased (from 1.7% to 17.5% and from 0.5% to 17.3%, respectively) between 2015 and 2021. Anticoagulant medication use rose from 45.9% in 2005 to 87.0% in 2021, primarily because of increased use of direct oral anticoagulant medications starting around 2010 and a decline in warfarin use. Antiplatelet use remained consistently high, at approximately 95%. Trends were consistent across subgroups of interest; however, overall medication use was lower in older patients (65 years and older), patients with severe stroke, and patients with neurologic and psychiatric comorbidities. DISCUSSION: Despite increasing trends in the use of 3 of 5 medication classes, the overall use of lipid-lowering, glucose-lowering, and oral anticoagulant medications was somewhat lower than expected according to clinical guidelines, particularly among older patients with more severe stroke and other comorbidities. The relatively low use in these subgroups may signify appropriate clinical decision making in consideration of frequent contraindications and reduced life expectancy or highlight potential areas of improvement for the care of patients with recent ischemic stroke.
Sujet(s)
Hypoglycémiants , Accident vasculaire cérébral ischémique , Enregistrements , Prévention secondaire , Humains , Danemark/épidémiologie , Sujet âgé , Femelle , Mâle , Accident vasculaire cérébral ischémique/épidémiologie , Accident vasculaire cérébral ischémique/traitement médicamenteux , Accident vasculaire cérébral ischémique/prévention et contrôle , Adulte d'âge moyen , Sujet âgé de 80 ans ou plus , Prévention secondaire/tendances , Prévention secondaire/méthodes , Hypoglycémiants/usage thérapeutique , Anticoagulants/usage thérapeutique , Hypolipémiants/usage thérapeutique , Antihypertenseurs/usage thérapeutique , Antiagrégants plaquettaires/usage thérapeutiqueRÉSUMÉ
ABSTRACT: We report process outcomes of the pilot randomized controlled trial of Texting 4 Relapse Prevention (T4RP), a text messaging-based relapse prevention program for people with schizophrenia or schizoaffective disorder (SAD). Forty people were randomized to either the intervention or treatment as usual control group at a 2:1 ratio. Process indicators were collected at 6 months post enrollment.Over 90% of patients agreed or strongly agreed that the text messages were easy to understand, easy to answer, positive, and helped them feel supported. Patient acceptability was positively associated with recovery (ß = 0.29, p = <0.001) and patient-provider communication scores (ß = 1.04, p < 0.001), and negatively associated with symptoms of the disorder (ß = -0.27, p = 0.07). Acceptability was similar by diagnosis (ß, SAD diagnosis = 0.40, p = 0.90) and age (ß = 0.05, p = 0.67). Findings suggest that a text messaging intervention aimed at preventing relapse is feasible and perceived as beneficial in individuals with schizophrenia and SAD. Future research might include a targeted study of T4RP within the context of hospital discharge when people with schizophrenia/SAD are at highest risk of relapse.
Sujet(s)
Troubles psychotiques/diagnostic , Troubles psychotiques/thérapie , Schizophrénie/diagnostic , Schizophrénie/thérapie , Prévention secondaire/méthodes , Envoi de messages textuels/tendances , Adulte , Femelle , Humains , Mâle , Adhésion au traitement médicamenteux/psychologie , Acceptation des soins par les patients/psychologie , Projets pilotes , Troubles psychotiques/psychologie , Prévention secondaire/tendancesRÉSUMÉ
BACKGROUND: Relatively high rates of adherence to myocardial infarction (MI) secondary prevention medications have been reported, but register-based, objective real-world data is scarce. We aimed to analyse adherence to guideline-recommended medications for secondary prevention of MI in 2017 to 2018 (period II) and compare the results with data from 2004 to 2005 (period I) in Estonia. METHODS: Study populations were formed based on data from the Estonian Health Insurance Fund's database and on Estonian Myocardial Infarction Register. By linking to the Estonian Medical Prescription Centre database adherence to guideline-recommended medications for MI secondary prevention was assessed for 1 year follow-up period from the first hospitalization due to MI. Data was analysed using the defined daily dosages methodology. RESULTS: Total of 6694 and 6060 cases of MI were reported in periods I and II, respectively. At least one prescription during the follow up period was found for beta-blockers in 81.0% and 83.5% (p = 0.001), for angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEi/ARB) in 76.9% and 66.0% (p < 0.001), and for statins in 44.0% and 67.0% (p < 0.001) of patients in period I and II, respectively. P2Y12 inhibitors were used by 76.4% of patients in period II. The logistic regression analysis adjusted to gender and age revealed that some drugs and drug combinations were not allocated similarly in different age and gender groups. CONCLUSIONS: In Estonia, adherence to MI secondary prevention guideline-recommended medications has improved. But as adherence is still not ideal more attention should be drawn to MI secondary prevention through systematic guideline implementation.
Sujet(s)
Agents cardiovasculaires/usage thérapeutique , Adhésion aux directives/tendances , Infarctus du myocarde/traitement médicamenteux , Guides de bonnes pratiques cliniques comme sujet , Types de pratiques des médecins/tendances , Prévention secondaire/tendances , Adulte , Sujet âgé , Sujet âgé de 80 ans ou plus , Utilisation médicament/tendances , Estonie/épidémiologie , Femelle , Disparités d'accès aux soins/tendances , Humains , Mâle , Adulte d'âge moyen , Infarctus du myocarde/diagnostic , Infarctus du myocarde/épidémiologie , Enregistrements , Facteurs temps , Résultat thérapeutique , Jeune adulteRÉSUMÉ
BACKGROUND: Optimal timing of oral anticoagulation (TOAC) in acute ischemic stroke (AIS) in patients with atrial fibrillation (AF) is unknown. The risk of recurrent ischemic events when treatment is delayed is often weighed against that of hemorrhagic transformation (HT) when anticoagulation is started in the subacute phase, especially in moderate to large infarctions. Despite substantial evidence for the benefit of oral anticoagulation (OAC) in reducing stroke recurrence, current nationally recognized practice guidelines do not provide clear recommendations on the TOAC after AF-related AIS. MATERIALS AND METHODS: We surveyed neurologists on therapeutic approaches to timing of anticoagulation after stroke in patients with AF (without moderate or severe mitral stenosis or a mechanical heart valve) using an online questionnaire. Several ischemic and hemorrhagic stroke scenarios with various stroke sizes, locations, and high-risk thrombotic complications were presented, and survey respondents were asked to provide post-stroke timeframe for TOAC. Practice background, specialty and years of experience of respondents were recorded. RESULTS: Majority of participants favored early initiation of OAC in small infarcts. In moderate to larger infarct burden, or when ischemia was complicated by HT, there was an overall trend to delay any initiation of OAC, irrespective of specialty or years of experience. The overt presence of an additional cardiac embolic source such as cardiac thrombus led decisions for early anticoagulation. CONCLUSION: Although general practice trends were captured, optimal TOAC following AIS in AF remains unknown. Further research is warranted to determine optimal timing and anticoagulant selection.
Sujet(s)
Anticoagulants/administration et posologie , Fibrillation auriculaire/traitement médicamenteux , Accident vasculaire cérébral ischémique/prévention et contrôle , Types de pratiques des médecins/tendances , Prévention secondaire/tendances , Délai jusqu'au traitement/tendances , Administration par voie orale , Anticoagulants/effets indésirables , Fibrillation auriculaire/complications , Fibrillation auriculaire/diagnostic , Études transversales , Calendrier d'administration des médicaments , Enquêtes sur les soins de santé , Humains , Accident vasculaire cérébral ischémique/diagnostic , Accident vasculaire cérébral ischémique/étiologie , Récidive , Facteurs temps , Résultat thérapeutiqueRÉSUMÉ
BACKGROUND: Smoking cessation after a first cardiovascular event reduces the risk of recurrent vascular events and mortality. This systematic review and meta-analysis aimed to summarize data on the rates, predictors, and the impact of smoking cessation in patients after a stroke or transient ischemic attack (TIA). METHODS: MEDLINE, EMBASE and Web of Science were searched to identify all published studies providing relevant data through May 20, 2021. Random-effects meta-analysis method was used to pool proportions. Some findings were summarized narratively. RESULTS: Twenty-five studies were included. The pooled smoking cessation rates were 51.0% (8 studies, n = 1738) at 3 months, 44.4% (7 studies, n = 1920) at 6 months, 43.7% (12 studies, n = 1604) at 12 months, and 49.8% (8 studies, n = 2549) at 24 months or more of follow-up. Increased disability and intensive smoking cessation support programs were associated with a higher likelihood of smoking cessation, whereas alcohol consumption and depression had an inverse effect. Two studies showed that patients who quit smoking after a stroke or a TIA had substantially lower risk of recurrent stroke, death, and a composite of stroke, myocardial infarction, and death. CONCLUSION: Smoking cessation in stroke survivors is associated with reduced recurrent vascular events and death. About half of smokers who experience a stroke or a TIA stop smoking afterwards. Those with low post-stroke disability, who consume alcohol, or have depression are less likely to quit. Intensive support programs can increase the likelihood of smoking cessation.
Sujet(s)
Accident ischémique transitoire/prévention et contrôle , Comportement de réduction des risques , Prévention secondaire/tendances , Arrêter de fumer , Fumer/effets indésirables , Accident vasculaire cérébral/prévention et contrôle , Humains , Accident ischémique transitoire/diagnostic , Accident ischémique transitoire/mortalité , Facteurs de protection , Récidive , Appréciation des risques , Facteurs de risque , Fumer/mortalité , Accident vasculaire cérébral/diagnostic , Accident vasculaire cérébral/mortalité , Facteurs temps , Résultat thérapeutiqueRÉSUMÉ
Clostridioides difficile is one of the most common nosocomial gastrointestinal pathogens, and recurrence is a problematic issue because approximately 20-30% of patients experience at least one episode of recurrence, even after treatment with a therapeutic drug of choice for C. difficile infection (CDI), such as vancomycin. CDI recurrence has a multifactorial complex mechanism, in which gut microbiota disruption coincident with viable C. difficile spores, is considered the most important factor. The effectiveness of an anti-C. difficile antimicrobial agent against CDI cannot guarantee its inhibitory effect on C. difficile spores and vice versa. However, an antimicrobial agent, such as fidaxomicin, which has a good inhibitory effect on both C. difficile vegetative cells and spores is assumed to not only treat CDI but also prevent its recurrence. Prolonged adherence to the exosporium has been proposed as a possible mechanism of inhibiting spores, and as a result, redesigning anti-C. difficile antimicrobial agents with the ability to adhere to the exosporium may provide another pathway for the development of anti-C. difficile spore agents. For example, vancomycin lacks an inhibitory effect against C. difficile spores, but a vancomycin-loaded spore-targeting iron oxide nanoparticle that selectively binds to C. difficile spores has been developed to successfully delay spore germination. Some new antimicrobial agents in phase II clinical trials, including cadazolid and ridinilazole, have shown exceptional anti-C. difficile and spore-inhibiting effects that can be expected to not only treat CDI but also prevent its recurrence in the future.
Sujet(s)
Antibactériens/usage thérapeutique , Clostridioides difficile/effets des médicaments et des substances chimiques , Infections à Clostridium/prévention et contrôle , Prévention secondaire , Spores bactériens/effets des médicaments et des substances chimiques , Clostridioides difficile/pathogénicité , Infections à Clostridium/traitement médicamenteux , Développement de médicament , Fidaxomicine/usage thérapeutique , Récidive , Prévention secondaire/tendances , Spores bactériens/pathogénicité , Vancomycine/usage thérapeutiqueRÉSUMÉ
New therapeutic approaches are required for secondary prevention of residual vascular risk after stroke. Diverse sources of evidence support a causal role for inflammation in the pathogenesis of stroke. Randomized controlled trials of anti-inflammatory agents have reported benefit for secondary prevention in patients with coronary disease. We review the data from observational studies supporting a role for inflammation in pathogenesis of stroke, overview randomized controlled trials of anti-inflammatory therapy in cardiac disease and discuss the potential implications for stroke prevention therapy.
Sujet(s)
Anti-inflammatoires/administration et posologie , Systèmes de délivrance de médicaments/tendances , Prévention secondaire/méthodes , Accident vasculaire cérébral/prévention et contrôle , Animaux , Colchicine/administration et posologie , Systèmes de délivrance de médicaments/méthodes , Antigoutteux/administration et posologie , Humains , Inflammation/diagnostic , Inflammation/épidémiologie , Inflammation/prévention et contrôle , Analyse de randomisation mendélienne/méthodes , Études observationnelles comme sujet/méthodes , Facteurs de risque , Prévention secondaire/tendances , Accident vasculaire cérébral/diagnostic , Accident vasculaire cérébral/épidémiologieRÉSUMÉ
BACKGROUND: The benefits of chronic polytherapy in reducing readmissions and death after myocardial infarction (MI) have been clearly shown. However, real-world evidence shows poor medication adherence and large geographic variation, suggesting critical issues in access to optimal care. Our objectives were to measure adherence to polytherapy, to compare the amount of variation attributable to hospitals of discharge and to community-based providers, and to identify determinants of adherence to medications. METHODS: This is a population-based study. Data were obtained from the information systems of the Lazio and Tuscany Regions, Italy (9.5 million inhabitants). Patients hospitalized with incident MI in 2010-2014 were analyzed. The outcome measure was medication adherence, defined as a Medication Possession Ratio (MPR) ≥ 0.75 for at least 3 of the following drugs: antiplatelets, ß-blockers, ACEI/ARBs, statins. A 2-year cohort-study was performed. Cross-classified multilevel models were applied to analyze geographic variation. The variance components attributable to hospitals of discharge and community-based providers were expressed as Median Odds Ratio (MOR). RESULTS: A total of 32,962 patients were enrolled. About 63% of patients in the Lazio cohort and 59% of the Tuscan cohort were adherent to chronic polytherapy. Women and patients aged 85 years and over were most at risk of non-adherence. In both regions, adherence was higher for patients discharged from cardiology wards (Lazio: OR = 1.58, p < 0.001, Tuscany: OR = 1.59, p < 0.001) and for patients with a percutaneous coronary intervention during the index admission. Relevant variation between community-based providers was observed, though when the hospital of discharge was included as a cross-classified level, in both Lazio and Tuscany regions the variation attributable to hospitals of discharge was the only significant component (Lazio: MOR = 1.30, p = 0.001; Tuscany: MOR = 1.31, p = 0.001). CONCLUSION: Adherence to best practice treatments after MI is not consistent with clinical guidelines, and varies between patient groups as well as within and between regions. The variation attributable to providers is affected by the hospital of discharge, up to two years from the acute episode. This variation is likely to be attributable to hospital discharge processes, and could be reduced through appropriate policy levers.
Sujet(s)
Agents cardiovasculaires/usage thérapeutique , Services de santé communautaires/tendances , Inhibiteurs de l'hydroxyméthylglutaryl-CoA réductase/usage thérapeutique , Adhésion au traitement médicamenteux , Infarctus du myocarde/prévention et contrôle , Sortie du patient/tendances , Types de pratiques des médecins/tendances , Antagonistes bêta-adrénergiques/usage thérapeutique , Adulte , Sujet âgé , Sujet âgé de 80 ans ou plus , Antagonistes des récepteurs aux angiotensines/usage thérapeutique , Inhibiteurs de l'enzyme de conversion de l'angiotensine/usage thérapeutique , Agents cardiovasculaires/effets indésirables , Bases de données factuelles , Femelle , Adhésion aux directives/tendances , Disparités d'accès aux soins/tendances , Humains , Inhibiteurs de l'hydroxyméthylglutaryl-CoA réductase/effets indésirables , Italie/épidémiologie , Mâle , Adulte d'âge moyen , Infarctus du myocarde/diagnostic , Infarctus du myocarde/épidémiologie , Antiagrégants plaquettaires/usage thérapeutique , Polypharmacie , Guides de bonnes pratiques cliniques comme sujet , Récidive , Études rétrospectives , Prévention secondaire/tendances , Facteurs temps , Résultat thérapeutiqueRÉSUMÉ
One in 3 individuals free of atrial fibrillation (AF) at index age 55 years is estimated to develop AF later in life. AF increases not only the risk of ischemic stroke but also of dementia, even in stroke-free patients. In this review, we address recent advances in the heart-brain interaction with focus on AF. Issues discussed are (1) the timing of direct oral anticoagulants start following an ischemic stroke; (2) the comparison of direct oral anticoagulants versus vitamin K antagonists in early secondary stroke prevention; (3) harms of bridging with heparin before direct oral anticoagulants; (4) importance of appropriate direct oral anticoagulants dosing; (5) screening for AF in high-risk populations, including the role of wearables; (6) left atrial appendage occlusion as an alternative to oral anticoagulation; (7) the role of early rhythm-control therapy; (8) effect of lifestyle interventions on AF; (9) AF as a risk factor for dementia. An interdisciplinary approach seems appropriate to address the complex challenges posed by AF.
Sujet(s)
Fibrillation auriculaire/complications , Fibrillation auriculaire/thérapie , Prévention secondaire/tendances , Accident vasculaire cérébral/étiologie , Accident vasculaire cérébral/prévention et contrôle , HumainsRÉSUMÉ
BACKGROUND: Adherence to clinical practice guidelines for coronary heart disease (CHD) reduces morbidity, mortality and treatment costs. We aimed to describe and compare adherence to prescription guidelines for persons with CHD, and explore its association with treatment goal achievement. METHOD: We included all participants reporting myocardial infarction, angina, percutaneous coronary intervention and/or coronary artery bypass surgery in the seventh wave of the Tromsø Study (2015-2016, n = 1483). Medication use and treatment goal measures (blood pressure, low-density lipoprotein (LDL)-cholesterol and HbA1c) were compared to clinical practice guidelines on secondary CHD prevention. Propensity score matched logistic regression was used to assess the association between the use of antihypertensive drugs and achievement of treatment goal for blood pressure, and the use of lipid-lowering drugs (LLDs) and achievement of treatment goal for LDL-cholesterol. RESULTS: The prevalence of pharmacological CHD treatment was 76% for LLDs, 72% for antihypertensive drugs and 66% for acetylsalicylic acid. The blood pressure goal (< 140/90 mmHg, < 140/80 mmHg if diabetic) was achieved by 58% and the LDL-cholesterol goal (< 1.8 mmol/l or < 70 mg/dL) by 9%. There was a strong association between using LLDs and achieving the treatment goal for LDL-cholesterol (OR 14.0, 95% CI 3.6-54.7), but not between using antihypertensive drugs and blood pressure goal achievement (OR 1.4, 95% CI 0.7-2.7). CONCLUSION: Treatment goal achievement of LDL-cholesterol and blood pressure was low, despite the relatively high use of LLDs and antihypertensive drugs. Further research is needed to find the proper actions to increase achievement of the treatment goals.
Sujet(s)
Antihypertenseurs/usage thérapeutique , Maladie coronarienne/prévention et contrôle , Adhésion aux directives/tendances , Hyperlipidémies/traitement médicamenteux , Hypertension artérielle/traitement médicamenteux , Hypolipémiants/usage thérapeutique , Guides de bonnes pratiques cliniques comme sujet , Types de pratiques des médecins/tendances , Prévention secondaire/tendances , Adulte , Sujet âgé , Sujet âgé de 80 ans ou plus , Marqueurs biologiques/sang , Pression sanguine/effets des médicaments et des substances chimiques , Cholestérol LDL/métabolisme , Maladie coronarienne/diagnostic , Femelle , Hémoglobine glyquée/métabolisme , Facteurs de risque de maladie cardiaque , Humains , Hyperlipidémies/sang , Hyperlipidémies/diagnostic , Hypertension artérielle/diagnostic , Hypertension artérielle/physiopathologie , Mâle , Adulte d'âge moyen , Norvège , Appréciation des risques , Facteurs temps , Résultat thérapeutiqueRÉSUMÉ
PURPOSE OF REVIEW: Single antiplatelet therapy represents an established treatment in secondary prevention of ischemic strokes and transient ischemic attacks (TIAs). In contrast with coronary artery disease, the use of dual antiplatelet therapy (DAPT) for secondary prevention in patients with acute cerebral ischemia (ACI) remains under debate. In this narrative review, we present and analyse the most recent findings concerning the potential efficacy and safety of DAPT therapy after ischemic strokes or TIA. RECENT FINDINGS: Following the publication of the three (CHANCE, POINT and THALES) large, randomized-controlled, clinical trials (RCTs) that showed efficacy of early DAPT for the secondary prevention after minor AIS or TIA, short-term DAPT use is becoming the most prevalent choice of treatment. Notably, DAPT is even more popular after AIS attributed to large artery atherosclerosis given randomized data from small RCTs supporting the use of DAPT in patients with extracranial or intracranial atherosclerosis and microembolization detected by transcranial Doppler. Recent subanalysis of data from the randomized trials aim to identify specific patient subgroups, which are determined by genetic, imaging or clinical characteristics, and for whom DAPT appears to be more beneficial. The potential role of different antiplatelet agents (aspirin, clopidogrel, ticagrelor) is also discussed. SUMMARY: DAPT has recently proven its efficacy for the early secondary prevention of AIS patients with minor stroke severity and high-risk TIA patients. However, the length of DAPT is still controversial, as well as the individualized selection of AIS or TIA patients with the lower risk of bleeding and with the greater benefit in prevention of ischemic cerebrovascular and cardiovascular events.
Sujet(s)
Hémorragie/prévention et contrôle , Accident ischémique transitoire/traitement médicamenteux , Antiagrégants plaquettaires/administration et posologie , Prévention secondaire , Acide acétylsalicylique/administration et posologie , Acide acétylsalicylique/effets indésirables , Encéphalopathie ischémique/complications , Encéphalopathie ischémique/traitement médicamenteux , Clopidogrel/administration et posologie , Clopidogrel/effets indésirables , Association de médicaments , Intervention médicale précoce/histoire , Intervention médicale précoce/méthodes , Intervention médicale précoce/tendances , Histoire du 21ème siècle , Humains , Accident ischémique transitoire/complications , Antiagrégants plaquettaires/effets indésirables , Prévention secondaire/histoire , Prévention secondaire/méthodes , Prévention secondaire/tendances , Accident vasculaire cérébral/complications , Accident vasculaire cérébral/traitement médicamenteuxSujet(s)
Maladie des artères coronaires , Infarctus du myocarde/prévention et contrôle , Analyse de l'onde de pouls/méthodes , Prévention secondaire , Accident vasculaire cérébral/prévention et contrôle , Vasodilatation , Index de pression systolique cheville-bras/méthodes , Vitesse du flux sanguin , Maladie des artères coronaires/complications , Maladie des artères coronaires/diagnostic , Maladie des artères coronaires/physiopathologie , Techniques de diagnostic cardiovasculaire , Humains , Ajustement du risque , Appréciation des risques/méthodes , Prévention secondaire/méthodes , Prévention secondaire/tendancesRÉSUMÉ
Importance: Atherosclerotic cardiovascular disease (ASCVD) is highly prevalent in the US, with studies indicating substantial rates of nonadherence to and undertreatment with statin therapy. The 2013 American College of Cardiology/American Heart Association guideline recommended high-intensity statins for all patients age 75 years and younger with documented ASCVD in whom such therapy is tolerated, but there is limited evidence documenting population trends of statin use, adherence, and outcomes in the periods before and after the update to the guideline. Objective: To assess trends in the use, adherence, cost, and outcomes of statin therapy for secondary prevention in patients with different types of ASCVD between 2007 and 2016. Design, Setting, and Participants: This retrospective cohort study used data from the OptumLab Data Warehouse database containing privately insured and Medicare Advantage enrollees with demographic characteristics similar to the national US population. Participants were adult patients (age ≥21 years) who had their first ASCVD event between January 1, 2007, and December 31, 2016. Data were characterized as belonging to 3 groups: (1) cardiovascular heart disease (CHD); (2) ischemic stroke or transient ischemic attack (TIA); and (3) peripheral artery disease (PAD). Data were analyzed from July 1 to August 1, 2018. Exposures: Calendar year of the initial ASCVD event. Main Outcomes and Measures: Trends in the statin use (within 30 days of discharge from hospitalization), adherence (proportion of days covered ≥80% within the first year), cost, major adverse cardiac events (1-year cumulative risk), and statin intolerance (within the first year). Results: Of the 284â¯954 patients with a new ASCVD event, 128â¯422 (45.1%) were women; the median age was 63 years (interquartile range [IQR], 54-72 years); 207â¯781 (72.9%) were White. The use of statins increased from 50.3% in 2007 to 59.9% in 2016, the use of high-intensity statins increased from 25.0% to 49.2%, and the adherence increased from 58.7% to 70.5% (P < .001 for all trends). Patients with CHD were more likely to receive statins and high-intensity statins and adhere to medications than patients with ischemic stroke, TIA, or PAD despite similar observed treatment benefit. In 2016, 80.9% of patients with CHD used a statin vs 65.8% of patients with ischemic stroke or TIA and 37.5% of patients with PAD. Out-of-pocket cost per 30-day decreased from a median of $20 (interquartile range, $7.6-$31.9) in 2007 to $2 (interquartile range, $1.6-$10.0) in 2016 (P < .001) with the increasing use of generic statins (42.0% in 2007 vs 94.9% in 2016; P < .001). Major adverse cardiac events decreased from 8.9% in 2007 to 6.5% in 2016 (P < .001) whereas statin intolerance increased from 4.0% to 5.1% (P < .001). Conclusions and Relevance: There have been modest improvements in the use, adherence, and cardiovascular outcomes over the past decade for statin therapy in patients with ASCVD, but a substantial and persistent treatment gap exists between patients with and without CHD, between men and women.
Sujet(s)
Athérosclérose/traitement médicamenteux , Maladie coronarienne/traitement médicamenteux , Inhibiteurs de l'hydroxyméthylglutaryl-CoA réductase/usage thérapeutique , Accident vasculaire cérébral ischémique/traitement médicamenteux , Adhésion au traitement médicamenteux/statistiques et données numériques , Maladie artérielle périphérique/traitement médicamenteux , Sujet âgé , Angine de poitrine/prévention et contrôle , Maladies cardiovasculaires/traitement médicamenteux , Études de cohortes , Maladie coronarienne/prévention et contrôle , Coûts des médicaments/tendances , Femelle , Dépenses de santé/tendances , Humains , Accident ischémique transitoire/traitement médicamenteux , Accident ischémique transitoire/prévention et contrôle , Accident vasculaire cérébral ischémique/prévention et contrôle , Modèles logistiques , Mâle , Medicare part C (USA) , Adulte d'âge moyen , Infarctus du myocarde/prévention et contrôle , Revascularisation myocardique , Maladie artérielle périphérique/prévention et contrôle , Modèles des risques proportionnels , Prévention secondaire/tendances , États-UnisRÉSUMÉ
INTRODUCTION: Oral anticoagulation (OAC) substantially reduces stroke risk in patients with atrial fibrillation (AF) at risk for stroke. Whether non-vitamin K-dependent oral anticoagulants (NOACs) improve OAC use in stroke prevention requires investigation. METHODS: To investigate temporal trends of OAC use in patients with known AF pre-stroke, we retrospectively analyzed records of 6,803 stroke patients admitted in 2003-2004 (n=1,496), 2008-2010 (n=1,638) or 2013-2015 (n=3,669) to the Charité-Universitätsmedizin Berlin, Germany. Adjusted regression models were used to identify factors associated with OAC use. RESULTS: Of 1,209 AF patients (mean age 79 years, 55.9% female) with given indication for OAC according to the CHADS2/CHA2DS2-VASc score, 484 (40.0%) were anticoagulated prior to the index stroke, 458 (37.9%) received antiplatelets and 236 (19.5%) had no antithrombotic medication. Compared to 2003-2004 and 2008-2010, there was a higher rate of pre-admission OAC in 2013-2015 (28.2% vs. 49.6%, p<0.001). After adjustment for possible confounders, factors associated with OAC pre-admission were young age (OR 0.74 per decade [95%CI 0.64-0.85]), previous stroke/TIA (OR 1.29 [95%CI 1.00-1.67]), absence of heart failure (OR 0.63 [95%CI 0.47-0.85]) and admission in 2013-2015 (OR 2.45 [95%CI 1.91-3.15]). Prescription of OAC at hospital discharge increased from 2003-2010 compared to 2013-2015 (45.2% vs. 69.5%, p < 0.001). CONCLUSIONS: Irrespective of temporal trends and despite given indication, more than half of all patients with known AF were not anticoagulated prior to the index stroke. In the NOAC era, there was an increase in OAC intake pre-stroke and a higher rate of OAC prescription at hospital discharge in stroke survivors with known AF.
Sujet(s)
Anticoagulants/administration et posologie , Fibrillation auriculaire/traitement médicamenteux , Encéphalopathie ischémique/prévention et contrôle , Fibrinolytiques/administration et posologie , Antiagrégants plaquettaires/administration et posologie , Types de pratiques des médecins/tendances , Prévention secondaire/tendances , Accident vasculaire cérébral/prévention et contrôle , Administration par voie orale , Sujet âgé , Sujet âgé de 80 ans ou plus , Anticoagulants/effets indésirables , Fibrillation auriculaire/diagnostic , Fibrillation auriculaire/épidémiologie , Encéphalopathie ischémique/diagnostic , Encéphalopathie ischémique/épidémiologie , Utilisation médicament/tendances , Femelle , Fibrinolytiques/effets indésirables , Allemagne/épidémiologie , Humains , Mâle , Antiagrégants plaquettaires/effets indésirables , Études rétrospectives , Facteurs de risque , Accident vasculaire cérébral/diagnostic , Accident vasculaire cérébral/épidémiologie , Facteurs temps , Résultat thérapeutiqueRÉSUMÉ
OBJECTIVE: Risk of early recurrent ischemic stroke in patients with atrial fibrillation may be high. ASA/AHA guidelines provide imprecise recommendations on the timing and anticoagulant choice for this indication. We assessed current opinions of stroke neurologists. METHODS: Case scenarios describing patients with acute ischemic stroke (AIS) due to paroxysmal atrial fibrillation (AF) were presented to US board-certified stroke neurologists in an internet-based questionnaire. Questions assessed timing and choice of anticoagulation for secondary stroke prevention, factors prompting earlier anticoagulation, reasons for specific anticoagulant choice, and alternatives to anticoagulation in ineligible patients. Open-ended comments were also solicited. RESULTS: Responses were available from 238/1239 stroke neurologists surveyed. In patients with small AIS without hemorrhagic transformation (HT), 51% elected to start anticoagulation within 96 hours. With increased stroke severity and asymptomatic HT, only 29% and 26% respectively chose to anticoagulate within 7 days. Few requested stability imaging before starting anticoagulation. With symptomatic HT the majority (79%) waited >14 days. 93% would anticoagulate earlier if left atrium/left atrial appendage or acute left ventricular thrombi, or mechanical heart valve were present. Direct oral anticoagulants (DOACs) were the preferred anticoagulation strategy (64%), and the remaining 38% preferred Warfarin. Aspirin was preferred by 57% in anticoagulation ineligible. CONCLUSION: Apart from AIS with symptomatic HT, there is a remarkable lack of consensus among stroke neurologists regarding the timing of anticoagulation for secondary stroke prevention in patients with AIS due to PAF. DOACs are the preferred anticoagulation strategy. More studies are required to clarify anticoagulant management in this patient population.
Sujet(s)
Anticoagulants/administration et posologie , Fibrillation auriculaire/traitement médicamenteux , Neurologues/tendances , Types de pratiques des médecins/tendances , Prévention secondaire/tendances , Accident vasculaire cérébral/prévention et contrôle , Administration par voie orale , Anticoagulants/effets indésirables , Fibrillation auriculaire/complications , Fibrillation auriculaire/diagnostic , Prise de décision clinique , Utilisation médicament/tendances , Enquêtes sur les soins de santé , Humains , Récidive , Facteurs de risque , Indice de gravité de la maladie , Accident vasculaire cérébral/diagnostic , Accident vasculaire cérébral/étiologie , Facteurs temps , Résultat thérapeutique , États-UnisRÉSUMÉ
This 6 month randomized control trial investigated whether a novel text-messaging program impacted targeted clinical outcomes in patients with schizophrenia and schizoaffective disorder (SAD). Forty patients were enrolled and completed baseline, 3-month and 6-month assessments. The intervention group received daily symptom check-in text messages, plus, a medication reminder or, inspirational quote text. The control group had treatment as usual. At 6 months the Positive and Negative Syndrome Scale mean positive score was significantly lower and injectable medication compliance was significantly higher in the intervention group. Recovery scores were significantly higher at 3 months. Results suggest that this program may benefit individuals with schizophrenia/SAD who use text messaging. Further investigation in a larger sample appears warranted.
Sujet(s)
Troubles psychotiques/diagnostic , Troubles psychotiques/thérapie , Schizophrénie/diagnostic , Schizophrénie/thérapie , Prévention secondaire/méthodes , Envoi de messages textuels , Adulte , Femelle , Études de suivi , Humains , Mâle , Adhésion au traitement médicamenteux/psychologie , Adulte d'âge moyen , Projets pilotes , Troubles psychotiques/psychologie , Psychologie des schizophrènes , Prévention secondaire/tendances , Envoi de messages textuels/tendancesRÉSUMÉ
Chronic spontaneous urticaria (CSU) is characterized by the presence of wheals, angioedema, or both for at least 6 weeks. It may persist for a long time-up to 50% of the patients have been reported to be symptomatic 5 years after the onset. Some patients can suffer more than one episode of CSU during their lifetime. Considering the recurrences, disabling symptoms, and significant impact on quality of life, proper and effective treatment of CSU is critical. The use of antihistamines (AHs) is still the mainstay of treatment. However, given the low rates of response to AHs (38.6% and 63.2% to standard doses and higher doses, respectively), the complete control of symptoms seems difficult to attain. The use of omalizumab for CSU has been a major breakthrough in the care of patients with CSU. However, the partial response and lack of response to omalizumab in a subgroup of patients, as high as 70% in some studies, make the development of alternative treatments desirable. Ever-increasing knowledge on the pathogenesis is making new target molecules available and enabling drug development for CSU. In addition to drug repurposing as in anti-IL-4/13, IL-5, and IL-17 antibodies, novel targeted therapy options such as ligelizumab and Bruton's tyrosine kinase inhibitors are currently undergoing clinical trials and will be available in the near future. This article reviews the current challenges in the treatment of CSU, the pathogenesis and potential target molecules, and the rationale for novel treatments and their rapidly developing status.
Sujet(s)
Antiallergiques/pharmacologie , Urticaire chronique/traitement médicamenteux , Antihistaminiques/pharmacologie , Inhibiteurs de protéines kinases/pharmacologie , Prévention secondaire/méthodes , Agammaglobulinaemia tyrosine kinase/antagonistes et inhibiteurs , Agammaglobulinaemia tyrosine kinase/métabolisme , Antiallergiques/usage thérapeutique , Anticorps monoclonaux humanisés/pharmacologie , Anticorps monoclonaux humanisés/usage thérapeutique , Urticaire chronique/immunologie , Urticaire chronique/psychologie , Développement de médicament/tendances , Antihistaminiques/usage thérapeutique , Humains , Interleukine-13/antagonistes et inhibiteurs , Interleukine-13/métabolisme , Interleukine-17/antagonistes et inhibiteurs , Interleukine-17/métabolisme , Interleukine-4/antagonistes et inhibiteurs , Interleukine-4/métabolisme , Interleukine-5/antagonistes et inhibiteurs , Interleukine-5/métabolisme , Thérapie moléculaire ciblée/méthodes , Omalizumab/pharmacologie , Omalizumab/usage thérapeutique , Inhibiteurs de protéines kinases/usage thérapeutique , Qualité de vie , Récidive , Prévention secondaire/tendances , Transduction du signal/effets des médicaments et des substances chimiques , Transduction du signal/immunologie , Résultat thérapeutique , Facteur de nécrose tumorale alpha/antagonistes et inhibiteurs , Facteur de nécrose tumorale alpha/métabolismeRÉSUMÉ
BACKGROUND AND PURPOSE: With recent advances in secondary prevention management, stroke recurrence rates may have changed substantially. We aim to estimate risks and trends of stroke recurrence over the past 2 decades in a population-based cohort of patients with stroke. METHODS: Patients with a first-ever stroke between 1995 and 2018 in South London, United Kingdom (n=6052) were collected and analyzed. Rates of recurrent stroke with 95% CIs were stratified by 5-year period of index stroke and etiologic TOAST (Trial of ORG 10172 in Acute Stroke Treatment) subtype. Cumulative incidences were estimated and multivariate Cox models applied to examine associations of recurrence and recurrence-free survival. RESULTS: The rate of stroke recurrence at 5 years reduced from 18% (95% CI, 15%-21%) in those who had their stroke in 1995 to 1999 to 12% (10%-15%) in 2000 to 2005, and no improvement since. Recurrence-free survival has improved (35%, 1995-1999; 67%, 2010-2015). Risk of recurrence or death is lowest for small-vessel occlusion strokes and other ischemic causes (36% and 27% at 5 years, respectively). For cardioembolic and hemorrhagic index strokes around half of first recurrences are of the same type (54% and 51%, respectively). Over the whole study period a 54% increased risk of recurrence was observed among those who had atrial fibrillation before the index stroke (hazard ratio, 1.54 [1.09-2.17]). CONCLUSIONS: The rate of recurrence reduced until mid-2000s but has not changed over the last decade. The majority of cardioembolic or hemorrhagic strokes that have a recurrence are stroke of the same type indicating that the implementation of effective preventive strategies is still suboptimal in these stroke subtypes.